Bubonic plague is typically caused by the bite of an infected flea, by contact with infected human/animal bodyilyfluids, or by touching or skinning infected animals [1]. Transmission by these routes can result in primary bubonic plague or in septicaemic plague [1]. Healthcare workers (HCW) can become infected during the management of an infected patient or during sample collection (e.g. collection of pus samples from swollen lymph nodes or buboes) [2].

Pneumonic plague

Pneumonic plague can be transmitted via infected respiratory droplets from infected humans or animals [3] [4], or through contact with infected human/animal body fluids [5]. It can also be transmitted by contact with bed linen/clothing contaminated with body fluids of an infected patient [5]. Human-to-human transmission by infected respiratory droplets can occur over a close distance, usually defined as less than two metres. Healthcare workers can become infected during the management of an infected patient or during sample collection (e.g. collection of sputum samples) [6].

Personal protective equipment for the management of possible, probable and confirmed cases of plague

Healthcare workers should be informed and trained on procedures and approaches to prevent and control infection. They should dispose of, disinfect or decontaminate all personal protective equipment (PPE) (disposable or not) used for the management of a plague patient according to the procedures for waste management [7]. They should also wash their hands frequently, particularly before putting on and after removing the PPE.

Bubonic plague

In line with the national and international infection prevention and control recommendations, HCW should wear the following PPE when managing or caring for a patient with possible, probable or confirmed bubonic plague:

The interim guidance on ‘How to safely collect pus samples from buboes of patients suspected to be infected with bubonic plague’ [2] should be followed for the specimens’ collection in case of suspected cases of bubonic plague.

Pneumonic plague

Healthcare workers should apply standard hygiene procedures for the management of the patient. They should isolate the patient [8] [9] and follow Body Substance Isolation (BSI) precautions [10] [11]. If isolation is not possible, they should ensure a separation of at least two metres between patients, and a dedicated bathroom for the infected patient. Health authorities should consider chemoprophylaxis for HCW in direct contact with pneumonic plague patients [9]. Due to the transmission route by droplets, these procedures should be continued for 48 hours after initiation of effective treatment [12].

In line with the national and international infection prevention and control recommendations, HCW should wear the following PPE when managing or caring for a patient with possible, probable or confirmed pneumonic plague:

The patient should wear a surgical mask if it is necessary to move him/her around the hospital; HCW should inform the patient about cough etiquette and respiratory hygiene. They should also follow the interim guidance on ‘How to safely collect sputum samples from patients suspected to be infected with pneumonic plague’ [6] for the specimens’ collection in case of suspected cases of pneumonic plague. Biosafety for the management of specimens All the samples collected for routine testing and cultures should be handled in Biosafety Level 2 (BSL-2) laboratories. Large-scale cultures and activities with high potential for droplet or aerosol production (centrifuging, grinding, etc.) require Biosafety Level 3 (BSL-3) conditions [13] [8].

Disclaimer ECDC issued this guidance document in accordance with Regulation (EC) No 851/2004 establishing a European centre for disease prevention and control. In the framework of ECDC’s mandate, the specific purpose of an ECDC guidance is to present different options on a certain matter. The responsibility on the choice of which option to pursue and which actions to take, including the adoption of mandatory rules or guidelines, lies exclusively with the EU/EEA Member States. In its activities, ECDC strives to ensure its independence, high scientific quality, transparency and efficiency.

A Tropical Storm Warning means that tropical storm conditions are
expected somewhere within the warning area, in this case within the
next 12-18 hours.

A Tropical Storm Watch means that tropical storm conditions are
possible within the watch area, in this case within 24 hours.

For storm information specific to your area in the United States,
including possible inland watches and warnings, please monitor
products issued by your local National Weather Service forecast
office. For storm information specific to your area outside the
United States, please monitor products issued by your national
meteorological service.

DISCUSSION AND 48-HOUR OUTLOOK
——————————
At 1100 PM EDT (0300 UTC), the center of Tropical Storm Philippe was
located near latitude 24.8 North, longitude 82.1 West. Philippe is
moving toward the north-northeast near 24 mph (39 km/h). A turn
toward the northeast is expected during the next few hours, and a
rapid motion toward the northeast is expected Sunday through
Monday. On the forecast track, the center of Philippe will move
across the Florida Keys or the southern tip of the Florida peninsula
overnight, and across the northwestern Bahamas Sunday morning.

Maximum sustained winds are near 40 mph (65 km/h) with higher gusts.
Some strengthening is forecast during the next 48 hours. However,
Philippe is expected to become a post-tropical cyclone on Monday.

Tropical-storm-force winds extend outward up to 105 miles (165 km)
mainly to the east and southeast of the center.

The estimated minimum central pressure is 1003 mb (29.62 inches).

HAZARDS AFFECTING LAND
———————-
RAINFALL: Across the northern Bahamas and south Florida including
the Keys rainfall amounts of 3 to 5 inches with isolated maximum
totals of 8 inches are expected through Sunday. These rainfall
totals may produce flash flooding, especially in urbanized areas.

Additional rainfall amounts of 1 to 2 inches are possible across
portions of western and central Cuba, which may lead to life-
threatening flash floods and mudslides in the higher terrain.

WIND: Tropical storm conditions are likely occurring in the
warning area across Cuba. Tropical storm conditions are expected to
occur in the warning area later tonight across the northwestern
Bahamas. Tropical storm conditions are possible across the upper
Florida Keys and southeast Florida overnight, and in the central
Bahamas by Sunday morning.

TORNADOES: An isolated tornado or two is possible across far South
Florida and the Florida Keys tonight.

Summary

What is already known about this topic?

The fourth United Nations Millennium Development Goal, adopted in 2000, set a target to reduce child mortality by two thirds by 2015. One indicator of progress toward this target was measles vaccination coverage.

What is added by this report?

For the first time, annual estimated measles deaths were fewer than 100,000, in 2016. This achievement follows an increase in the number of countries providing the second dose of measles-containing vaccine (MCV2) nationally through routine immunization services to 164 (85%) of 194 countries, and the vaccination of approximately 119 million persons against measles during supplementary immunization activities in 2016. During 2000–2016, annual reported measles incidence decreased 87%, from 145 to 19 cases per million persons, annual estimated measles deaths decreased 84%, from 550,100 to 89,780, and an estimated 20.4 million deaths were prevented. However, the 2015 measles elimination milestones have not yet been met, and only one World Health Organization region has been verified as having eliminated measles.

The fourth United Nations Millennium Development Goal, adopted in 2000, set a target to reduce child mortality by two thirds by 2015. One indicator of progress toward this target was measles vaccination coverage (1). In 2010, the World Health Assembly (WHA) set three milestones for measles control by 2015: 1) increase routine coverage with the first dose of a measles-containing vaccine (MCV1) among children aged 1 year to ≥90% at the national level and to ≥80% in every district; 2) reduce global annual measles incidence to <5 cases per million population; and 3) reduce global measles mortality by 95% from the 2000 estimate (2).* In 2012, WHA endorsed the Global Vaccine Action Plan,† with the objective of eliminating measles in four World Health Organization (WHO) regions by 2015 and in five regions by 2020. Countries in all six WHO regions have adopted goals for measles elimination by or before 2020. Measles elimination is defined as the absence of endemic measles virus transmission in a region or other defined geographic area for ≥12 months, in the presence of a high quality surveillance system that meets targets of key performance indicators. This report updates a previous report (3) and describes progress toward global measles control milestones and regional measles elimination goals during 2000–2016. During this period, annual reported measles incidence decreased 87%, from 145 to 19 cases per million persons, and annual estimated measles deaths decreased 84%, from 550,100 to 89,780; measles vaccination prevented an estimated 20.4 million deaths. However, the 2015 milestones have not yet been met; only one WHO region has been verified as having eliminated measles. Improved implementation of elimination strategies by countries and their partners is needed, with focus on increasing vaccination coverage through substantial and sustained additional investments in health systems, strengthening surveillance systems, using surveillance data to drive programmatic actions, securing political commitment, and raising the visibility of measles elimination goals.

Immunization Activities

To estimate coverage with MCV1 and the second dose of measles-containing vaccine (MCV2) through routine immunization services,§ WHO and the United Nations Children’s Fund (UNICEF) use data from administrative records (administrative coverage is calculated by dividing the vaccine doses administered by the estimated target population) and immunization coverage surveys reported annually by 194 countries. During 2000–2016, estimated MCV1 coverage increased globally from 72% to 85% (Table 1), although coverage has not increased since 2009. Considerable variability in regional coverage exists. Since 2012, MCV1 coverage has remained essentially unchanged in the African Region (AFR) (72%), the Region of the Americas (AMR) (92%), and the Eastern Mediterranean Region (EMR) (77%). In the European Region (EUR), MCV1 coverage has declined from 95% to 93% since 2012, with 51% of EUR member states reporting lower coverage since 2013. In the South-East Asia Region (SEAR), MCV1 coverage increased slightly since 2012, from 84% to 87%. The Western Pacific Region (WPR) is the only region that has achieved and sustained MCV1 coverage >95% (since 2008). Since 2000, the number of countries with MCV1 coverage of ≥90% increased globally from 85 (44%) in 2000 to 119 (61%) in 2015, and to 123 (63%) in 2016. However, among countries with ≥90% MCV1 coverage nationally, the percentage with ≥80% MCV1 coverage in all districts declined from 46% (52 of 112) in 2010 to 45% (49 of 110) in 2015 and 36% (44 of 123) in 2016. Among the estimated 20.8 million infants who did not receive MCV1 through routine immunization services in 2016, approximately 11 million (53%) were in six countries with large birth cohorts and suboptimal coverage: Nigeria (3.3 million), India (2.9 million), Pakistan (2.0 million), Indonesia (1.2 million), Ethiopia (0.9 million), and the Democratic Republic of the Congo (0.7 million).

During 2000–2016, the number of countries providing MCV2 nationally through routine services increased from 98 (51%) to 164 (85%), with four countries (Guatemala, Haiti, Papua New Guinea, and Timor-Leste) introducing MCV2 in 2016. Estimated global MCV2 coverage steadily increased from 15% in 2000 to 60% in 2015 and 64% in 2016 (Table 1). During 2016, approximately 119 million persons received supplementary doses of measles-containing vaccine (MCV) during 33 mass immunization campaigns, known as supplementary immunization activities (SIAs),¶ implemented in 31 countries (Table 2). Based on doses administered, SIA coverage was ≥95% in 20 (61%) SIAs. Among the six countries that conducted post-SIA coverage surveys, estimated coverage was ≥95% in three, 90%–94% in two, and 84% in one.

Disease Incidence

Countries report the aggregate number of incident measles cases**,†† to WHO and UNICEF annually through the Joint Reporting Form. In 2016, 189 (97%) countries conducted case-based surveillance in at least part of the country, and 191 (98%) had access to standardized quality-controlled testing through the WHO Global Measles and Rubella Laboratory Network. Nonetheless, surveillance was weak in many countries; fewer than half of countries (64 of 134; 48%) achieved the sensitivity indicator target of two or more discarded measles and rubella§§ cases per 100,000 population in 2016 compared with 2015 (80 of 135; 59%).

During 2000–2016, the number of measles cases reported annually worldwide decreased 85%, from 853,479 in 2000 to 214,812 in 2015 and then to 132,137 in 2016; measles incidence decreased 87%, from 145 to 19 cases per 1 million population (Table 1). Compared with 2015, 2016 incidence decreased from 29 to 19 cases per million, although three fewer countries (173 of 194; 89%) reported case data in 2016 than did in 2015 (176 of 194; 92%).¶¶ The percentage of reporting countries with fewer than five measles cases per million population increased from 38% (64/169) in 2000 to 69% (119/173) in 2016. During 2000–2016, measles incidence of fewer than five cases per million was sustained in AMR (Table 1).

During 2015–2016, the number of reported measles cases declined globally and in all regions (AFR, 31%; AMR, 98%; EMR, 71%; EUR, 84%; SEAR, 44%, and WPR, 11%). In addition to aggregate reporting, countries report measles case-based data to WHO monthly. In some countries large discrepancies exist between the two reporting systems. During 2016, some countries either did not report or reported only a fraction of monthly reported measles cases through the Joint Reporting Form (e.g., India reported 70,798 measles cases through monthly reporting, but only 17,250 through the Joint Reporting Form).

Genotypes of viruses isolated from measles cases were reported by 60 (55%) of the 110 countries that reported at least one measles case in 2016. Among the 24 recognized measles virus genotypes, 11 were detected during 2005–2008, eight during 2009–2014, six in 2015, and five in 2016, excluding those from vaccine reactions and cases of subacute sclerosing panencephalitis, a fatal progressive neurologic disorder caused by persistent measles infection (4).*** In 2016, among 4,796 reported measles virus sequences,††† 666 were genotype B3 (36 countries); 44 were D4 (four); 1,407 were D8 (43); 87 were D9 (four); and 2,592 were H1 (13).

Disease and Mortality Estimates

A previously described model for estimating measles disease and mortality was updated with new measles vaccination coverage data, case data, and United Nations population estimates for all countries during 2000–2016, enabling derivation of a new series of disease and mortality estimates (5). Based on the updated data, the estimated number of measles cases declined from 29,068,400 (95% confidence interval [CI] = 20,606,800–55,859,000) in 2000 to 6,976,800 (95% CI = 4,190,500–28,657,300) in 2016. During this period, the number of estimated measles deaths declined 84%, from 550,100 (95% CI = 374,000–896,500) in 2000 to 89,780 (95% CI = 45,700–269,600) in 2016 (Table 1). Compared with no measles vaccination, measles vaccination prevented an estimated 20.4 million deaths during 2000–2016 (Figure).

Regional Verification of Measles Elimination

In 2016, four WHO regions had functioning regional verification commissions. In September 2016, the AMR regional verification commission declared the region free of endemic measles (6). In 2016, the EUR commission verified measles elimination in 24 countries (7). Two SEAR countries (Bhutan and Maldives) were verified as having eliminated measles in 2017 (8). The WPR commission reclassified Mongolia as having reestablished endemic measles virus transmission because of an outbreak that lasted >12 months; thus, five WPR countries (Australia, Brunei, Cambodia, Japan, and South Korea) and two areas (Macao Special Autonomous Region [SAR] [China] and Hong Kong SAR [China]) had verified measles elimination status in 2016 (9).

Discussion

During 2000–2016, increased coverage with MCV administered through routine immunization programs worldwide, combined with SIAs, contributed to an 87% decrease in reported measles incidence and an 84% reduction in estimated measles mortality. Measles vaccination prevented an estimated 20.4 million deaths during this period, and during 2016, for the first time ever, estimated measles deaths declined to fewer than 100,000. Furthermore, the number of countries with measles incidence of fewer than five per million population has increased, although considerable underreporting occurred, and AMR has maintained an incidence of fewer than five cases per million population during 2000–2016. The decreasing number of circulating measles virus genotypes suggests interruption of some chains of transmission. However, the 2015 global control milestones were not met, global MCV1 coverage has stagnated, global MCV2 coverage has reached only 64%, and SIA quality was inadequate to achieve ≥95% coverage in several countries. With suboptimal MCV coverage, outbreaks continued to occur among unvaccinated persons, including school-aged children and young adults.

The 2016 Mid-term Review of the Global Measles and Rubella Strategic Plan 2012–2020 concluded that measles elimination strategies were sound, and the WHO Strategic Advisory Group of Experts on Immunization endorsed its findings. The review noted, however, that implementation of the strategies needs improvement. Measures should focus on strengthening immunization and surveillance systems. The Measles and Rubella Initiative should increase its emphasis on using surveillance data to drive programmatic actions.

The findings in this report are subject to at least three limitations. First, SIA coverage data might be biased by inaccurate reports of the number of doses delivered, doses administered to children outside the target age group, and inaccurate estimates of the target population size. Second, large differences between the estimated and reported incidence indicate variable surveillance sensitivity, making comparisons between countries and regions difficult to interpret. Finally, the accuracy of the results from the measles mortality model is affected by biases in all model inputs, including country-specific measles vaccination coverage and measles case-based surveillance data.

The decrease in measles mortality to fewer than 100,000 deaths in 2016 is one of five main contributors (along with decreases in mortality from diarrhea, malaria, pneumonia, and neonatal intrapartum deaths) to the decline in overall child mortality worldwide and progress toward the fourth United Nations Millennium Development Goal, but continued work is needed to help achieve measles elimination goals (10). Of concern is the possibility that the gains made and future progress in measles elimination could be reversed when polio-funded resources supporting routine immunization services, measles SIAs, and measles surveillance diminish and disappear after polio eradication. Countries with the highest measles mortality rely most heavily on polio-funded resources and are at highest risk for reversal of progress after polio eradication is achieved. Improved implementation of elimination strategies by countries and their partners is needed, with focus on increasing vaccination coverage with substantial and sustained additional investments in health systems, strengthening surveillance systems, using surveillance data to drive programmatic actions, securing political commitment, and raising the visibility of measles elimination goals.

26 October 2017 – The Ministry of Public Health and Population of Yemen has reported a cumulative total of 862858 suspected cases of cholera including 2177 associated deaths as of 26 July for the outbreak which started in October 2016.

The overall case-fatality rate remains low (0.25%). There has been a modest decrease in the number of suspected cholera cases and deaths compared to previous weeks, and the overall trend appears to be stable.

While cholera is endemic in Yemen, the country has experienced a surge in cholera cases since April this year, with nearly 5000 cases reported per day. Ongoing conflict, destroyed health, water and sanitation infrastructure and malnutrition have caused the people to be more vulnerable to diseases, including cholera and other endemic infectious diseases.

WHO and health partners support the Ministry through the cholera task force to improve cholera response efforts at the national and local levels. This includes delivering 20 tonnes of medicines and intravenous (IV) fluids to Ibb governorate; the establishment of diarrhoea treatment facilities and oral dehydration centres; training of health workers to manage cases, water purification in communities, deployment of rapid response team to manage cholera cases investigations and respond to the outbreak, and enhancement of Yemen’s disease early warning surveillance systems.

• Pneumonic plague is transmitted between humans most often by inhaling infected respiratory droplets. The transmission happens at close distance (usually defined as less than two metres) and only symptomatic patients are infectious.

• The infection can cause severe disease in humans but can be successfully treated with antibiotics, especially if antibiotic treatment is insituted early.

• A case of pneumonic plague can be suspected on aircraft or ships when a traveller (passenger or a crewmember) leaving an affected area has fever associated with persistent coughing and/or impaired breathing.

• The training of crewmembers and the increase in their awareness should reduce the risk of transmission on-board.

• A surgical mask and standard infection control precautions can be used to effectively reduce the spread of droplets from a suspected patient, if isolation measures are not possible.

• A surgical mask can be used to protect travellers (passengers and crewmembers) from infection by a suspected pneumonic plague case.

• Local authorities of the arrival airport/mooring port of call should be kept informed immediately after the identification of a suspected case of pneumonic plague on-board, in order to plan for mitigating the risks of further spread.

• All passengers should be advised about self-monitoring of plague compatible symptoms in case of an onboard event; collection of passenger contact details is crucial for further contact tracing.

• Early post-exposure prophylaxis should be considered for passengers and crewmembers who came into close contact with the ill passenger.

• After disembarkation, disinfection measures should be considered which comply with relevant national and international recommendations.